The FAA Medical
Getting a medical with insulin-treated diabetes.
Since 2019, the FAA has certified insulin-treated pilots for first- and second-class medicals through a Special Issuance built on continuous glucose monitoring. This page explains how that pathway works, in plain language, drawn directly from the FAA's published protocol.
This page is not medical, legal, or aeromedical certification advice. DAPA is a peer community — not the FAA, not an AME, and not a medical provider. What follows is a plain-language summary of public FAA documents (revised August 30, 2023 and December 3, 2025) so you know what to expect. Requirements change, and your situation is specific to you. Confirm everything against the current FAA Guide for Aviation Medical Examiners, and make decisions with your AME and endocrinologist. See our Disclaimer & Terms of Use.
The process
Diagnosis to Authorization, step by step.
This follows the FAA's own "Pilot Information – Initial Certification" sequence.
Stop flying and get healthy.
Under 14 CFR 61.53 you may not act as a required crewmember with a known medical deficiency. From diagnosis until you hold an Authorization from the FAA, you are grounded. See your treating physician first; the paperwork comes later.
Find an AME who will work the process with you.
Your AME is your interface with the FAA. For ITDM the AME cannot issue an initial certificate — the application must be deferred to Oklahoma City — but the AME assembles and uploads your package. An AME experienced with Special Issuances is worth finding. Use the FAA Designee Locator to search AMEs by location, and ask directly whether they have handled insulin-treated cases.
Establish care with a board-certified endocrinologist.
The FAA requires an M.D. or D.O. endocrinologist, not a mid-level practitioner, for the initial comprehensive evaluation. You will be seeing this practice every three months, and this physician in person at least every six, for as long as you hold the certificate — so choose well.
Choose an FAA-compliant CGM with your endocrinologist.
The device must be a real-time CGM (not intermittently scanned) with predictive trend arrows, customizable alerts, and a MARD of 10% or less. Alarms and repeat alarms must be ON. Device details are below.
Collect at least six months of CGM data.
Separate it by calendar month. The FAA wants to see consistent, effective use and stable control — not just numbers that hit targets. Weekly overlay graphs with frequent excursions below 70 or above 250 mg/dL can jeopardize eligibility even when the summary statistics look fine.
Complete the rest of the package within a 90-day window.
- Comprehensive endocrinologist evaluation (the actual clinical progress note, not a letter)
- Lab panel, plus every A1c from the past 12 months
- Eye evaluation from a board-certified ophthalmologist — an optometrist is not accepted
- Cardiac risk evaluation from a board-certified cardiologist, with ECG at any age and a Bruce-protocol stress test at 40 and older
See your AME. Complete a new 8500-8. Submit everything at once.
The AME transmits the exam as deferred and uploads your documents through AMCS — each document separately, CGM data by month, in color. The FAA asks that a complete package arrive within 14 days; partial packages are not reviewed and delay everything.
While under review, keep the file current.
Continue submitting your endocrinologist report and monthly CGM printouts every three months. If the FAA has to request current data, the review stalls.
Authorization Letter — and the renewal cycle begins.
The letter spells out your ongoing requirements. Your AME may not re-issue a certificate unless the letter specifically says so. Renewal cadence is covered below.
The initial package
The five items, in detail.
The evaluations and current labs must be performed within the 90 days before submission; the A1c history and CGM data reach back six to twelve months. Item numbers match the FAA's own requirements sheet.
Item 1Initial comprehensive endocrinologist evaluation
An in-person evaluation by your treating board-certified endocrinologist (M.D. or D.O.). You submit the actual detailed clinical progress note — the FAA will not accept a patient encounter summary or a letter. The note must address:
Diabetes history
- Onset, previous treatment and response, hospitalizations, complications, and comorbidities
- Lifestyle: eating patterns, weight, sleep, activity, carbohydrate counting, tobacco/alcohol/substance use, any diabetes-related motor vehicle incidents
- Medication compliance and side effects, glucose monitoring data use, insulin pump settings
- Screening for depression, anxiety, and disordered eating; cognitive assessment if indicated; self-management education
- Hypoglycemia in the past 12 months: any symptomatic episode requiring treatment or assistance by another person, and sustained episodes (below 70 mg/dL for over 30 minutes or below 54 for over 15)
- Hyperglycemia in the past 12 months: symptomatic episodes and sustained episodes (above 250 mg/dL for over 60 minutes or above 300 for over 30)
Physical exam
- Height, weight, BMI, pulse, blood pressure (orthostatic when indicated)
- Thyroid and skin exam, including injection or insertion sites
- Comprehensive foot exam: visual inspection, pedal pulses, temperature/vibration/pinprick sensation, 10-g monofilament
Assessment and plan
- Current status, compliance, stability, and your ability to recognize and respond to highs and lows
- Prognosis for the next 12 months and any recommended treatment changes
- Date of next follow-up (the FAA requires every three months)
Item 2Laboratory panel
Drawn within the past 90 days:
- A1c — current, plus all prior values from the preceding 12 months
- CBC (complete blood count)
- Lipids: total cholesterol, LDL, HDL, triglycerides
- Liver function tests
- Microalbumin or spot urinary albumin-to-creatinine ratio
- Renal function: serum creatinine, BUN, eGFR
- TSH
- Vitamin B12 and potassium when clinically indicated (potassium also if taking ACE inhibitors, ARBs, or diuretics)
Item 3Continuous glucose monitor data
Monthly CGM data for the preceding six months (up to twelve when available), from a device that meets FAA requirements. Submit the original digital reports, in color, and do not submit daily or hourly pump statistics.
Dexcom users submit, for each month
- Overview Report
- Ambulatory Glucose Profile (AGP) Report
- Alert Settings (showing high and low alarms and repeat alarms ON)
- Weekly overlays for every week of the month
Medtronic users submit, for each month
- Assessment & Progress Report
- Weekly overlays for every week of the month
Other devices
- Reports must show estimated A1c or GMI, average glucose, coefficient of variation, standard deviation, time in range, sensor usage, alarm settings, device model, and weekly graphs
The data is evaluated against the CGM targets in the table below and against the weekly graphs for consistency.
Item 4Eye evaluation
From a board-certified ophthalmologist (M.D. or D.O.), within the past 90 days. An exam by an optometrist (O.D.) is not acceptable. The evaluation must include:
- Visual acuity, corrected and uncorrected, each eye and together, at near, intermediate, and distance
- Evaluation for cataracts, color vision deficiency, contrast sensitivity, depth perception, intraocular pressure, and visual field defects, with the test and method used for each
- Dilated fundus exam documenting the absence or degree of retinopathy
- Diagnosis, prognosis, and recommendations
Item 5Cardiac risk evaluation
From a board-certified cardiologist (M.D. or D.O.), not a mid-level practitioner, within the past 90 days — again the actual clinical progress note, not a summary or letter.
- Assessment of cardiac risk factors with lab
- Baseline ECG regardless of age
- Maximal treadmill (Bruce protocol) stress test beginning at age 40, every five years thereafter, and at any age when clinically indicated
- If anything is abnormal, a detailed report on diagnosis, symptoms, risk-factor control, treatment, further testing, and annualized risk of an acutely disabling cardiovascular event
CGM goals
The numbers the FAA looks for.
Targets for certification consideration, from the FAA's Initial Certificate Consideration Requirements. Meeting them is necessary but not sufficient: the weekly overlays must also show consistent control with minimal excursions below 70 or above 250 mg/dL.
| Parameter | Target for consideration |
|---|---|
| Time in range 70–180 mg/dL | 70% or greater |
| Overall readings 70–250 mg/dL | 90% or greater |
| Readings below 70 mg/dL | less than 4% |
| Readings below 54 mg/dL | less than 1% |
| Readings above 250 mg/dL | less than 5% |
| Glucose Management Indicator (GMI) | less than 7% |
| Coefficient of variation | ≤ 36% (< 33% preferred) |
| Sensor wear | 90% of the time or greater |
| Auto mode (closed-loop pumps) | greater than 90% |
Why 70–250? The FAA's FAQ describes 70–250 mg/dL as the safety band; time in range for treatment purposes is the tighter 70–180. Both appear in the targets. The FAA's FAQ notes that hypoglycemia can cause cognitive impairment, loss of consciousness, and seizure, and that hyperglycemia can cause sudden incapacitation as well as long-term organ damage. Separately, it explains that its testing follows current standards of care because end-organ damage raises the risk of cognitive impairment, which could be magnified in a hypoxic or high-stress environment.
Devices
CGM and pump requirements.
The CGM must
- Be FDA-approved and appropriate for your age
- Be a real-time CGM that transmits automatically — intermittently scanned devices do not qualify
- Provide predictive trend arrows warning of highs and lows before they occur
- Allow customizable low and high glucose alerts, with alarms and repeat alarms turned ON
- Have an overall MARD of 10% or less
- Produce reports with monthly TIR, average glucose, standard deviation, CV, and weekly graphs
- Be your own unblinded device — not shared, not a professional blinded unit
Devices the FAA listed as meeting the features (as of Aug 30, 2023)
The FAA notes the list may not be all-inclusive; a device that meets every feature requirement above may qualify.
If you use a pump
A pump is not required. If you use one:
- It must be able to suspend insulin for a predicted low glucose or predicted pressure change
- The insulin must be FDA-approved for pump use
- Pump and CGM must be FDA-approved both separately and as a combination
- Self-built (DIY) systems are not acceptable for flying
Ground time
- Starting a pump for the first time: seven-day ground trial
- Changing from one pump or CGM to another, or open-loop to closed-loop: no ground time
Pump-specific cautions from the FAA
- Carry a backup insulin delivery method in case of failure
- On sudden cabin depressurization, consider turning off or disconnecting the pump
- Clear tubing bubbles that appear with cabin pressure changes
- Confirm with your operator that your devices are approved personal electronic devices for the aircraft you fly (see AC 20-164A)
After you're certified
The renewal cycle.
Your Authorization Letter governs. In general, the FAA's CGM Renewal Certificate Requirements run on the cadence below.
Every 3 months
- Comprehensive endocrinology clinical examination. Every 6-month visit must be in person with your endocrinologist; the interval visits may be virtual or with a PA/NP in the practice
- Obtain the detailed clinical progress note from each visit — a letter is not sufficient
Every 6 months
- Submit the endocrinologist notes plus monthly CGM data reports for the previous six months, separated by month
Every 12 months
- Everything in the 3- and 6-month cycle, plus the annual lab panel
- Eye evaluation from a board-certified ophthalmologist
- Age 40 and older: cardiac risk evaluation from a board-certified cardiologist, with ECG and stress testing as indicated (stress test at least every five years)
Every 24 months
- Under age 40: cardiac risk evaluation from your endocrinologist or a cardiologist, with lab and ECG/stress testing as indicated
Already on a Special Issuance for something else? The FAA's FAQ states an existing SI becomes invalid with the additional ITDM diagnosis; you will need a new Authorization Letter covering both.
On the line
What the FAA expects in flight.
From the FAA's ITDM FAQ. Your Authorization Letter and your endocrinologist's plan take precedence.
Carry every flight
- Glucometer and test strips
- Backup sensor for the CGM
- Backup insulin pen, if you use a pump
If the CGM fails
- Switch to your backup plan and fingerstick every 30 minutes for the remainder of the flight
- If you cannot correct your glucose, treat it as an in-flight emergency and land as soon as practicable
If something goes wrong
Symptoms or impairment from glucose
- Self-disqualify from flight activities, as required by the SI and 61.53
- Contact your endocrinologist about treatment changes
- Contact your AME with details; your AME should discuss the case with the FAA
Device breaks or supplies run out on a trip
- Replace it as soon as possible
- If you cannot, finish the scheduled trip on your backup system (fingersticks and injections) while staying compliant with the SI
- Do not add legs to the trip, and do not start a new trip until the authorized system is back in place
- If neither primary nor backup is functional, terminate flight activity
Third class (private flying). Third-class applicants may use either the CGM protocol above or the FAA's older non-CGM protocol. The FAA states there are no restrictions on flight outside U.S. airspace; third-class airmen who currently hold a certificate carrying that limitation will have it removed with their next certificate, and can contact AMCD to have it removed sooner. This page focuses on the first- and second-class pathway, which is what a professional career requires.
Where to get help
Start here.
The source, and the people who do this for a living. DAPA is not affiliated with any of them.
The FAA protocol
Everything on this page comes from one FAA page: the Guide for Aviation Medical Examiners entry for "Diabetes Mellitus Type I or Type II – Insulin Treated – CGM Option." It holds all eight documents — pilot information, initial and renewal requirements, the certification aid, the information submission form, instructions for submitting documents, CGM report examples, and the FAQ. Read it before you do anything else.
Find an Aviation Medical Examiner
The FAA's Designee Locator lists every current AME by city, state, and ZIP code. Not every AME has worked an insulin-treated Special Issuance — when you call, ask. An AME who knows the ITDM package will save you months.
Aviation Medicine Advisory Service (AMAS)
Aviation medicine physicians who work directly with pilots and related aviation professionals to navigate FAA medical certification, confidentially. For a Special Issuance case, a consultation before your package goes to the FAA can catch gaps that would otherwise cost months. Some pilot unions provide AMAS access as a member benefit — check with yours first.
Glossary
The vocabulary.
- AME
- Aviation Medical Examiner. The FAA-designated physician who performs your medical exam and submits your application. For ITDM, the AME cannot issue an initial certificate and must defer to the FAA.
- SI
- Special Issuance. An FAA authorization to hold a medical certificate with a condition that would otherwise be disqualifying, subject to monitoring requirements in your Authorization Letter.
- ITDM
- Insulin-Treated Diabetes Mellitus. The FAA's term for Type 1 or Type 2 diabetes managed with insulin. The protocol is the same for both.
- CGM
- Continuous Glucose Monitor. The FAA's first- and second-class pathway is built on CGM data, not fingersticks.
- AGP
- Ambulatory Glucose Profile. A standardized CGM summary report the FAA asks Dexcom users to submit.
- GMI
- Glucose Management Indicator. An estimated A1c calculated from CGM data.
- TIR
- Time in Range. The percentage of readings between 70 and 180 mg/dL.
- CV
- Coefficient of Variation. A measure of glucose variability; the FAA wants 36% or less.
- MARD
- Mean Absolute Relative Difference. A CGM accuracy rating; the FAA requires 10% or less.
- 8500-8
- The FAA medical application form, completed through MedXPress and finalized at your AME visit.
- AMCS
- Aerospace Medical Certification Subsystem. The FAA system your AME uses to upload your documents.
- 61.53
- 14 CFR 61.53: the regulation prohibiting flight operations during a known medical deficiency. It is why you stop flying at diagnosis.
- AMCD
- Aerospace Medical Certification Division, Oklahoma City. The FAA office that reviews Special Issuance files.
- Bruce protocol
- A maximal treadmill exercise stress test. Required at age 40 and every five years after.
- faa.gov/ame_guide/dec_cons/disease_prot/itdm — the protocol page, with all documents
DAPA does not provide medical or legal advice. Where this summary and the FAA's current documents differ, the FAA's documents control.
You don't have to figure this out alone.
DAPA is a peer community of aviation professionals who have been through the Special Issuance process. Join, ask questions, and compare notes.
